Efficacy of preparation solutions and cleansing techniques on contamination of the skin in foot and ankle surgery

A systematic review and meta-analysis

K. Yammine, A. Harvey


We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001).

Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S&P) followed by alcohol showed significantly better efficacy over PI (S&P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S&P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.

Cite this article: Bone Joint J 2013;95-B:498–503.


  • No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    This article was primary edited by G. Scott and first-proof edited by D. Rowley.

  • Supplementary material. Six tables, detailing a) the modified Cochrane Collaboration’s tool for assessing risk of bias, b) and c) the summary of post-preparation culture number (Post-PCN) results by groups of comparison, d) the analyses undertaken on the Post-PCN results, and e) and f) summary and analyses of subgroup comparisons undertaken on the data, are available with the electronic version of this article on our website www.bjj.boneandjoint.org.uk

  • Received November 11, 2012.
  • Accepted December 19, 2012.
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